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The future of paediatric accident and emergency medicine F®on Davies MRCP FFAEM J R Soc Med 2000;93:484±486
SECTION OF ACCIDENT & EMERGENCY, 28 JANUARY 2000
The past decade has seen the specialty of accident and emergency (A&E) medicine expanding rapidly, in terms of numbers of specialists, size of departments, training of junior doctors, and complexity of care delivered. Subspecialty areas have developed, with A&E consultants linking into pre-hospital care, critical care, acute general medicine, sports medicine, academic emergency medicine and paediatrics. Since children form 25±30% of attendances in most A&E departments, this is by far the largest area of emergency care in which special arrangements need to be considered. Children are different physically, physiologically and psychologically and present with different patterns of illness and trauma from adults. Indeed, the pattern of disease itself has changed in recent years: traf®c-related accidents have decreased, along with sudden infant deaths (reduced by 70% since 1990) and medical diseases such as serious Haemophilus in¯uenzae infections, mumps and measles. Further, the standard of care delivered to children has seemingly improved. The mortality from trauma, adjusted for injury severity score, showed a steady decline in the 1990s2. During this time, courses such as Advanced Paediatric Life Support, Advanced Trauma Life Support and Pre-Hospital Paediatric Life Support have become widespread nationally, and their principles have been incorporated in teaching at all levels. The better outcomes probably owe something, also, to improvement of basic skills in large numbers of staff. Lastly, the emphasis of paediatric healthcare has moved away from the inpatient setting, with development of ambulatory care, home care schemes that employ senior paediatric nurses with extended skills and involvement of community consultants. Consequently there is more diagnosis and discharge planning in A&E departments, some of which now have short-term ambulatory/admission areas.
children's hospitals and the support specialties available on site. For hospitals without inpatient children's services on site, children must be transferred if admission is required. Children may be treated by paediatricians or A&E doctors, and this may depend on the age or diagnosis of the child. The role of the A&E department can range from basic triage and rapid referral, to extensive treatment and investigation within A&E. This variation makes standardization of practice dif®cult. However, in 1999 a working party convened by the Royal College of Paediatrics and Child Health (RCPCH), with representatives from the British Association of A&E Medicine, the British Association of Paediatric Surgeons, the Royal College of Nursing and the Royal College of General Practitioners, published a document Accident & Emergency Services for Children1 setting standards for the next ®ve and ten years. It is practical and realistic, and most of the standards should be attainable in the time frame suggested. Data from Thames Regions in 1999 (Brown R, personal communication) indicated that, of eleven RCPCH benchmarks, the following seven were already commonly achieved:
THE CURRENT POSITION
. At least one children-trained nurse on each shift . A play therapist.
There are now over 200 A&E departments in the UK, most of which receive children. Practice and case-mix vary widely depending on geographical location, proximity to Accident and Emergency Department, Royal London Hospital, Whitechapel
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Auditory and visual separation of children from adults Play facilities and suitable decoration Inpatient paediatric facilities on site Written child protection policy and training of staff Designated consultant paediatrician to liaise with A&E Advanced Paediatric Life Support (APLS) or PLS for all nurses and doctors providing emergency care to children . A system for auditing frequent attenders. Only a minority of departments offered:
Very few yet had: . A consultant who has undertaken signi®cant training in both paediatrics and A&E . Observation beds for children.
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PAEDIATRIC A&E AS A SUBSPECIALTY
The development of paediatric A&E will make the emergency management of sick and injured children a skilled area, and should improve the standard of care. The provision of services for children will range, depending usually on the size of the A&E department, from simply a separate waiting area, to a fully ¯edged 24-hour service, with an emphasis on training. Each department will need to balance factors such as geography, staf®ng, expertise with children and demand for such services. Within A&E departments, dedicated paediatric areas are growing in number. The main drive behind this development is to provide a child and family centred environment, away from potentially unpleasant or frightening scenes. The waiting time for children also tends to improve. However, a geographically separate area can dilute A&E resources (both manpower and equipment), and many operate only at busy periods because of inadequate nursing numbers. A separate paediatric area creates a sense of ownership within the staff, attracts interested nurses and facilitates development of the unit. Larger units may develop their own staf®ng structure, with a more complex nursing skill-mix and potential for rotations between `adult A&E', paediatric ambulatory care or the wards. Where paediatric facilities have been developed, several questions arise. How should this area operate? Who is responsible for the children, either clinically or manageriallyÐwhich doctors, nurses or directorate? Total separation of the paediatric area from the A&E department risks losing some important principles and skills of emergency medicine. Also, A&E specialist registrar (SpR) training is threatened unless time in the paediatric A&E is built in to the rota (they are required to spend 25% of their time in A&E seeing children). The hospitals must resolve these issues locally, with A&E and paediatrics working together towards common goals. Operationally, in the hospital management structure, larger units require a voice in both directorates, to ensure the optimal care of children.
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combines the skills of both specialties; SpRs in either paediatrics or A&E may be trained in this way, and many of the arguments about who is `better' at providing such care then fade away. Guidelines for training have been produced by the Joint Committee on Higher Training (A&E) and are available from the Faculty of A&E Medicine, but they have yet to be rati®ed by the Specialist Training Authority. Both paediatric and A&E SpRs can achieve this training within the ®ve years of higher specialist training. In educational terms, spreading paediatric A&E training through the ®ve-year SpR programmes enables the SpR to acquire different skills (from clinical to managerial) as he or she matures. This is preferable to `tagging it onto the end'. Some SpRs have now embarked on such training schemes, emulating what has happened in North America for several years. During this evolutionary period, accreditation for both the trainers and training hospitals will have to be ¯exible. Accreditation based purely on new patient attendances may not re¯ect quality of training. Similarly, restricting training to teaching or children's hospitals means that applicability may be limited for these future consultants of district general hospitals. Training for paediatric specialist registrars
Paediatric SpRs choose their area of special interest at the end of year two. This could be followed by a three-year A&E oriented programme, which could expand on the periods of time suggested by the JCHT (A&E). The trainee undertakes all secondments on a supernumerary basis, but should aim to remain `hands on' within his or her skill level. These secondments include adult A&E, the different models of ambulatory care, and paediatric subspecialties such as anaesthesia and intensive care, orthopaedics, and surgery (including eye clinics, ENT clinics, neurosurgery, plastic surgery and maxillofacial surgery). Training objectives would include: .
TRAINING IN PAEDIATRIC A&E
Large numbers of both paediatricians and A&E specialists are currently expressing an interest in paediatric A&E. There is no allowance for a Certi®cate of Completion of Specialist Training (CCST) in paediatric A&E in the European Specialist Register, but in future there is some prospect that consultants holding CCST in either paediatrics or A&E will be able to declare a special interest in paediatric A&E. Currently, consultants are appointed on the strength of their previous experience, with additional training usually gained towards the end of SpR training, on an individual, ad hoc, basis. Inevitably, such individuals remain much stronger in their original specialty. The ideal future consultant
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Assessment and treatment of trauma, major and minor (since paediatric major trauma is rare, the basic skills should be enhanced by exposure to adult trauma) Exposure to mental illness, drug and alcohol misuse, and gynaecological and sexual health disorders Con®dence in non-neonatal resuscitation and team leadership How to manage large numbers of unselected patients by triage and rapid assessment, organization of skill-mix of staff and patient ¯ow, and problem-solving skills and clinical risk management How to interface smoothly and ef®ciently with many other specialties, support services (e.g. radiology, pathology) and the community (primary care, police, ambulance and voluntary services).
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Training for A&E specialist registrars
For CCST in A&E, SpRs require a minimum of three years' training in A&E, plus three months of each of ®ve `core secondments' (medicine with cardiology, general surgery, orthopaedics, paediatrics and anaesthesia). Since at least two of these have usually been studied at senior house of®cer level, this leaves some ¯exibility within the ®ve-year programme, allowing time for extra training in paediatric A&E. Training would include paediatric A&E, ambulatory paediatrics and the other paediatric subspecialties listed. Periods of time back in adult A&E are essential, so as not to lose those skills. A quarter of the patients seen during the three years' general A&E will, of course, be children. Training objectives would include: . . . . . . .
Development of a child and family centred approach Communication skills with children Practical skills such as cannulation and intubation Familiarity with childhood illnesses, including surgical and neonatal conditions Familiarity with community-based care Developmental assessment Diagnosis and handling of non-accidental injury, child sex abuse and factitious illness.
For individual departments, the choice of consultant (derived from either career structure) will depend on local circumstances such as whether he or she would take part in the A&E or the paediatric on-call rota and would also see adults in A&E (not possible for those derived purely from paediatrics). THE FUTURE OF THE SERVICE
Paediatric A&E is already becoming established as a subspecialty and there is a high demand for suitably trained doctors. In the near future more training programmes will become ®rmly established and available to trainees, although few centres are at present able to provide this. Similar developments are happening in paediatric A&E nursing. Nationally, we are seeing a trend towards `one-stop shop' medicine, driven by high public expectation. The
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paediatric ambulatory care sector will expand, and hospital diagnostic services will see the balance shift to rapid, outpatient, requests for their services. The role of the emergency nurse practitioner is well established in adult practice, and extended nursing skills apply just as much in children as in adults. In parallel with these changes in hospital practice, growing links are evolving between A&E departments and primary care cooperatives and new walk-in centres. With the development of primary care trusts, some general practitioners may in future choose to undertake more general paediatric work. One of the great obstacles to progress is the lack of commitment to consultant expansion at national level. With the major reduction in SpR numbers in paediatrics and a similar threat to A&E numbers, it is hard to see how emergency paediatric services can develop to their full potential. Lastly, it is time we looked at the basic infrastructure of paediatric services within the National Health Service, in terms of how prehospital, emergency, secondary and tertiary services relate to each other. This particularly applies to intensive care and trauma services in large urban conurbations. Until this matter is addressed in our larger cities, we will continue to underserve our children. Meanwhile, the threat of closure of smaller rural paediatric units may leave many A&E departments without inpatient support. In view of the trends of the last ten years, there is room for optimism that children will in future receive a higher basic standard of emergency care, and in many cases specialist emergency care delivered by appropriately trained staff. This will be achieved by collaboration between the specialties of paediatrics and A&E.
REFERENCES
1 Royal College of Paediatrics and Child Health. Accident & Emergency Services for Children. Report of a Multidisciplinary Working Party. London: RCPCH, 1999 2 Roberts I, Campbell F, Hollis S, Yates D. Reducing accident death rates in children and young adults: the contribution of hospital care. BMJ 1996;313:1239±41
